Provider Demographics
NPI:1427157593
Name:KING SPINAL & SPORTS REHABILITATION, LTD.
Entity type:Organization
Organization Name:KING SPINAL & SPORTS REHABILITATION, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:KING
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:618-452-1986
Mailing Address - Street 1:PO BOX 1343
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-1343
Mailing Address - Country:US
Mailing Address - Phone:618-452-1986
Mailing Address - Fax:618-452-6814
Practice Address - Street 1:1525 JOHNSON RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3831
Practice Address - Country:US
Practice Address - Phone:618-452-1986
Practice Address - Fax:618-452-6814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
06032044OtherBC/BS OF ILLINOIS
K27018Medicare ID - Type Unspecified
T38285Medicare UPIN